Every day at 7 p.m. during the pandemic, New Yorkers have been going to their windows with any noisemaker they can find to bang, ring, honk, clap, and holler their support for health care workers—from ambulance drivers and orderlies to nurses and physicians. And every day at that hour, Stephen Krieger, MD, FAAN, associate professor of neurology at the Icahn School of Medicine at Mount Sinai in New York, would feel a twinge of guilt.

Although he had agreed to be part of a redeployment team at the hospital, the multiple sclerosis (MS) specialist was not called on for weeks. Then, on April 27, he was assigned to a COVID-19 unit, and his twinge of guilt was replaced with a surge of pride that he was finally doing his part.

"It was a daunting feeling," Dr. Krieger says of his first day. "I hadn't practiced inpatient medicine in a very long time, but the skills I learned during my one year of internal medicine came back pretty quickly." By the time he was redeployed, protocols about treatment were well set and resources were readily available at his hospital, which eased his transition into COVID work.

He was gratified to discover how much his training as a neurologist and an MS expert prepared him for taking care of COVID-19 patients. "MS is a diverse disease, and everyone presents differently, so I have to be very thorough in my examination," Dr. Krieger says. "That thoroughness and holistic approach definitely came into play while treating patients with COVID, which affects a whole variety of organ systems." He was also familiar with other disciplines, such as immunology and virology. "When we talked about immune modifiers or steroids or ways to tamp down the immune system, I had a greater fluency on these topics because MS is an autoimmune disorder."

But nothing in Dr. Krieger's interactions with MS patients prepared him for the style of care in the COVID unit. "I was used to having 30 minutes with my patients and engaging in thoughtful conversations where I really got to know them," he says. "With COVID patients, everyone is gowned up, and we get in and out of the rooms quickly to minimize exposure. And clinical conversations with colleagues are much more curtailed."

Despite those constraints, Dr. Krieger did everything he could to reassure his patients. "Anytime I saw the oxygen levels increase, I would take a moment to celebrate that with the patient. I tried to be encouraging at every appropriate opportunity." His goal was to counter patients' fears. "Everyone was terrified that all the terrible stories they'd heard in the media about this disease were now happening to them. I felt it was important to convey good news to the patients and their families whenever I had it."

Working Together

Neurologists and other physicians around the country are saying collaboration has been key during the pandemic. For hospitals treating COVID patients, teamwork has been a recurring theme—from the doctors in charge all the way through to the maintenance and custodial staff. Integral personnel include food service workers who bring boxed meals to patients staying in emergency departments, supply room staff who deliver swabs and gowns, and couriers transporting lab work.

"If any link in the chain breaks, patients aren't getting what they need," says Sarah Levy, MD, a neurology resident at Mount Sinai who was deployed at Elmhurst Hospital in Queens at the peak of the pandemic. Dr. Levy cites oxygen as an example: "For COVID patients, it dictates everything, and getting enough oxygen tanks in the room was essential. The tanks came from maintenance staff who filled them up from a central oxygen supply and then brought them up and moved empty tanks out to be refilled." Seamless coordination has been crucial, she says.

So has mental fortitude. "These patients require so much bloodwork, and every time a doctor puts in an order, a nurse has to interact with patients dozens of times, which requires emotional strength to consolidate tasks and protect themselves," Dr. Levy says. Work conditions for medical staff in a COVID-19 unit can be exhausting in other ways. "The mask makes it hard to breathe, the shield over the mask is heavy, the din of the negative pressure in the room and the respirators means you have to speak loudly to be heard, and you can hardly hear your own voice but you need to communicate," explains Dr. Levy. X-rays for COVID patients are done on a portable machine by technicians wearing personal protective equipment (PPE).

But even while dealing with a deadly pandemic, the work can be rewarding. "One of the most productive interventions was awake proning," says Dr. Levy, referring to the practice of rotating patients from their backs to their sides or stomachs to raise their oxygen levels. ("Awake" means they aren't intubated or sedated.) "It's really low-tech and effective and can empower patients if they feel they have some control over their symptoms."

Another hallmark of working during the COVID-19 crisis has been learning so much so fast. "You think of clinical trials and how long it takes to get results and how changes can take years," says Dr. Krieger. "We were learning about this disease and how best to take care of it over days and weeks."

Ramping Up

Knowledge gleaned from hospitals at the epicenters of the outbreak helped inform hospitals that had later surges, like Chicago's Rush University Medical Center. "We learned more about delivering oxygen, different ventilation settings, best intubation practices, and to assume that all stroke patients were positive for COVID-19," says James Conners, MD, medical director of Rush's comprehensive stroke program.

Rush has been ahead of the game to an extent, says Dr. Conners, thanks to a facility it opened in 2012 to handle a mass influx of patients in just this kind of scenario. "It allows us to add beds and increase our capacity easily."

As the hospital saw an increase in COVID-19 patients, it saw a marked decrease in other acute conditions such as heart attack and stroke. "Stroke calls to emergency medical services in Chicago were down about 25 percent, and our emergency department volumes overall were down significantly," says Dr. Conners. "People may have been afraid to come to the hospital for fear of infection." At Emory University Hospital in Atlanta, staff also reported a drop in the number of stroke patients. "People were waiting to come in," says Terri Milburn, NP-C, an Emory inpatient neurology nurse practitioner. "Some of them were having symptoms for three or four days or even two weeks."

For people having a stroke, the delay in seeking medical attention could be catastrophic, Dr. Conners says, because treatments have to be administered within hours. Tissue plasminogen activator (tPA), a clot-busting drug, must be given within four and a half hours of the start of stroke symptoms. Endovascular thrombectomy, a procedure to remove a clot from the brain via an artery in the groin, ideally is performed within six hours of a stroke (though it can be done up to 24 hours after). While Dr. Conners has treated fewer stroke patients than usual in recent months, he says the ones he has seen had major strokes that required more invasive procedures and had worse outcomes.

One of the challenges of treating stroke patients during COVID-19 is that the infection can mimic some stroke symptoms, including confusion and slurred speech. "If a patient came into the hospital in an altered mental state but had no focal neurologic symptoms such as facial droop or numbness," says Dr. Conners, the emergency department would have to first confirm whether the patient had had a stroke, coronavirus, or both. "It was important to determine what was and was not COVID to minimize exposure and conserve PPE."

In addition to potential PPE shortages, testing time has been a concern in treating COVID-19 patients. It could take 24 to 48 hours to get results. Even a new bedside test that was supposed to take five minutes took at least 15, says Dr. Conners. "Testing didn't have the impact on acute care that I had hoped."

Otherwise, the process from admission to discharge was well controlled and efficient, he says. Rush set up a triage area for people who came to the hospital with COVID symptoms. Deborah Lynch, APRN, a clinical nurse specialist and coordinator in the Rush Stroke Program, was assigned to that drive-through unit, where she would assess patients' symptoms and determine whether they should be sent to the emergency department or could go home. "If they tested positive but were well enough to recover at home, we had to explain how to quarantine," says Lynch. "Communicating that wasn't always easy, especially while wearing a face mask and shield."

With many COVID patients but fewer patients overall, hospitals have had a different atmosphere, says Emory's Milburn. "It definitely was tense, but it wasn't frantic," she says. "It got almost eerily quiet because the hallways were empty of visitors and elective patients. It was like a permanent night shift."

Procedures in the emergency department changed for staff, too, adds Milburn. "There was a warm zone and a hot zone. You couldn't pass from one zone to the other without wearing your PPE. For a stroke alert, we would put the N95 mask on before heading down there and don our other gear once we got there."

Serving Patients

While Milburn has treated several COVID patients, she says the most exhausting work takes place in the COVID intensive care unit. "They are in PPE their whole shift, and they are taking care of very sick patients," says Milburn. "If you're in an N95 mask all the time, you're not going to be hydrated or taking regular food and drink breaks. Some of my colleagues complained of headaches and not sleeping as well."

For many frontline staff, however, the stress and sacrifice have been worth it. "I felt I was contributing to the welfare of patients and representing the field of neurology," says Dr. Krieger of Mount Sinai. "We were in the arena and not sidelined. That felt gratifying."

Like many of her colleagues, Dr. Levy has served as a liaison between patients and their families. "If there was a phone call I could make or if I could deliver food to patients from their family, that was one of the most important things I could do," she says.

She recalls, in particular, her interaction with an elderly patient whose son hadn't been able to ride with him in the ambulance. The man had several underlying medical conditions (and later tested positive for COVID)and was in a state of confusion, but his son was most upset that he couldn't tend to him. When she spoke to the son on the phone, he was worried about his father being cold. So Dr. Levy got the patient a blanket—offering him the comfort that his family couldn't provide in person. "It wasn't his chronic illnesses that bothered the family most," Dr. Levy says. "It was their not being able to be with him."